1 Legislative Alert March 5, 2015 Fees for employer-sponsored health plans under the ACA The Patient Protection and Affordable Care Act (ACA) assesses three fees (two for selffunded plans) on employer-sponsored health plans. In aggregate, early estimates indicate that all three fees could increase gross premiums from 1.5% to 5% over healthcare trend. This article discusses all three fees in detail and concludes with a chart highlighting the key features of each fee. Patient-Centered Outcomes Research Trust Fund Fee The Patient-Centered Outcomes Research (PCOR) Trust Fund Fee helps fund research that evaluates and compares health outcomes, clinical effectiveness, and the risks and benefits of medical treatments and services. It will apply to all group health plans, whether insured or self-insured, as described in greater detail below. This is a relatively small fee as it amounts to just $1 per covered member per plan year in the first year, $2 per covered member per year in year two, then the fee increases to $2 per member plus an inflation factor, for the following five plan years. The fee is no longer applicable after seven years. For insured plans, the insurance carrier will be responsible for paying the fee and it is expected that the insurance carriers will pass this fee along to policyholders. Self-insured plans will be responsible for filing Form 720 on an annual basis and paying the fee to the Internal Revenue Service. For this reason, the following information for determining and paying the fee will be most significant for sponsors of self-insured plans. Fee timing of payment The timing for plans to first be subject to the PCOR Fee, and when the fee is to be paid, can be confusing. The ACA provides that it is first due for the first plan year that ends after September 30, 2012, while subsequent guidance provides that it becomes payable as of July 31st of the year following the calendar year in which the relevant plan year ends. Assuming that all plan years start or renew as of the first day of a month, the first fee payment was due on July 31, 2013 for plans with a plan year that ended October 31, 2012, November 30, 2012, or December 31, This means that plans with plan years beginning between November 1 and January 1 will be responsible for paying the fee by July 31, Plans with plan years beginning on February 1 through October 1, 2012, will have to first pay the fee on July 31, Covered plans Applicable self-insured health plans to which the fee applies will include all private and public (including governmental and Native American tribal government)
2 Legislative Alert Page 2 self-insured group health plans, retiree-only plans, and multiemployer plans. The plan sponsor usually the employer is responsible for paying the fee for those plans. The following plans will generally not be subject to the PCOR Fee: Health flexible spending arrangements (FSAs) that are excepted benefits (generally, health FSAs offered in conjunction with a group plan where only employees contribute to the health FSA, or where employer contributions to the health FSA are $500 or less) Stand-alone dental and visions plans (for selfinsured plans, those that require a separate election and an additional premium) Employee assistance plans (EAPs) and wellness plans that do not provide significant benefits in the nature of medical care or treatment. The proposed rules provide no additional guidance on the meaning of this phrase, but the preamble suggests this means that benefits for medical care are secondary or incidental to non-medical benefits. Any group policy issued to an employer where the facts and circumstances show that the plan or policy was adopted/issued specifically to cover primarily employees who are working and residing outside the U.S. This would include a non-u.s. citizen residing in the U.S. on a temporary U.S. visa. Note that health reimbursement arrangements (HRAs) are typically self-insured group health plans. If the HRA is integrated with a self-insured major medical plan, the HRA plan is not subject to a separate fee. However, if an HRA that is integrated with an insured group health plan, it is treated as a separate self-insured plan subject to the fee, for which the plan sponsor is responsible. Paying the PCOR fee The PCOR Fee will be paid by filing IRS Form 720 (Quarterly Federal Excise Tax Return). Form 720 is due annually by July 31st of the year following the year in which an applicable plan s plan year ends. To view a copy of Form 720 and instructions please visit Counting enrollees The PCOR Fee is payable on the average number of lives covered under the plan, which number sponsors of selfinsured plans are responsible for calculating. Plan sponsors essentially have three options for determining the number of lives covered: Actual count method. The sum of the lives covered for each day of the plan year, divided by the number of days in the plan year. Snapshot method. Add the totals of lives covered on one date in each quarter, or more dates if an equal number of dates are used for each quarter, and divide that total by the number of dates on which a count was made. To account for dependents enrolled in the plan, the number of lives covered on a date may be determined as equal to either the sum of the actual number of lives covered on the dates (the snapshot count method) or the sum of the number of participants with self-only coverage on that date plus the number of participants with coverage other than self-only coverage on the date multiplied by 2.35 (the snapshot factor method). Form 5500 method. Based on the number of reportable participants for the Form 5500 that is filed for the applicable self-insured health plan for that plan year. For most plans, which provide coverage for multiple tiers (self-only, employee plus spouse, employee plus family, etc.), the method allows a plan sponsor to simply add the number of participants reported on a 5500 for the beginning of the plan year to the number reported for the end of the plan year to determine the average number of covered lives for the plan year. For a plan that happens to provide only self-only coverage, the plan sponsor may treat the average number of covered lives under the plan for a plan year as the sum of the total participants at the beginning and the end of the plan year, in each case as reported on the Form 5500, divided by two. In order to use the Form 5500 method, the plan sponsor must have filed the Form 5500 by the due date for the PCOR fee for that year. If the plan sponsor files an extension (as is common for Form 5500 filings), it may not be able to use this method. Plan sponsors may only apply a single method in determining the average number of lives covered under the plan for the entire plan year. However, a sponsor is not required to use the same method from one plan year to the next. A plan sponsor may want to try one or more of the above methods prior to its initial filing date to determine which method works best for its plan.
3 Legislative Alert Page 3 Transitional Reinsurance Fee The Transitional Reinsurance Fee applies to all plans, fully- insured and self-insured, and begins in It only applies for three years (2014, 2015, and 2016) and then ceases. The 2014 fee is $63 per person, collected in two installments: $52.50 in January 2015 and $10.50 late in the fourth quarter of The first installment would cover the reinsurance payments and administrative expenses needed for the daily operations of the reinsurance program and the second would cover payments to the U.S. Treasury that are not needed for the daily operation of the reinsurance program. For 2015, the fee is $44 per person, $33 towards reinsurance payments and administrative expenses payable in January 2016 and $11 towards payments to the U.S. Treasury payable late in the fourth quarter of For 2016, the proposed fee is $27 per person, $21.60 towards reinsurance payments and administrative expenses payable in January 2016 and $5.40 towards payments to the U.S. Treasury payable late in the fourth quarter of Contributing entities may pay the entire reinsurance contribution amount with the first installment. For 2015 and 2016, self-insured group health plans are excluded from paying reinsurance contributions if they do not use a third-party administrator (TPA) for the core administrative functions of claims processing or adjudication, or plan enrollment. This exclusion applies to self-insured plans that use TPAs solely for obtaining provider network and related claim repricing services, for a de minimis percentage (up to 5%) of a plan s core administrative functions, or for core administrative functions relating only to pharmacy or excepted benefits. Self-insured plans also may use TPAs for certain ancillary administrative support and still be considered self-administered for purposes of the exemption. Purpose and responsible parties This fee is intended to create a pool of funds that the Department of Health and Human Services (HHS) may use to reimburse insurance carriers for excess losses that they expect to incur initially under the ACA through guaranteed issue policies offered through insurance exchanges and to protect carriers from adverse selection so that they are able to set the premiums for exchange coverage without having to add a risk adjustment. For insured plans, carriers are directly liable for payment of reinsurance contributions. Since related insurance policies generally require policyholders to reimburse the carrier for taxes and other government payments (other than income taxes), employers can fully expect to have to reimburse carriers for their reinsurance contributions either in a separate bill or in the form of higher insurance premiums. For self-insured plans, sponsors are generally responsible for payment of reinsurance contributions, but they may use the services of a thirdparty administrator in making payments. Covered plans Most insured and self-insured group major medical plans are subject to the fee. However, the following plans are not subject to the fee: Plans that consist solely of excepted benefits under HIPAA, such as: Stand-alone dental and vision care insurance policies, and self-insured dental and vision care plans that require employee contributions and permit employees to opt out of coverage Fixed dollar indemnity policies Disease-specific policies Health reimbursement arrangements (HRAs) that are integrated with an underlying insured or self-insured major medical group health plan Health savings accounts (HSA), although reinsurance contributions are required for related high-deductible health plans Health flexible spending arrangements (FSAs) Employee assistance plans, disease management programs, or wellness programs that do not provide major medical coverage Stop-loss insurance policies or indemnity reinsurance policies Insurance plans or coverage provided by a Native American nation to enrollees, in their capacity as members, but not in their capacity as current or former employees Expatriate health coverage Retiree-only HRAs Any other plan or coverage that is not major medical coverage The annual reinsurance contribution is calculated by taking the federal contribution rate, adding the state contribution rate (if any), and multiplying the combined rate by the annual enrollment count. The proposed regulations permit different contributing entities to determine the annual enrollment count in different ways, as shown in Exhibit A at the end of this document.
4 Legislative Alert Page 4 Paying the fee Proposed regulations provide that every insurance carrier and self-insured plan must notify the U.S. Department of Health and Human Services (HHS) by November 15th of the relevant year (that is, for the first year, 2014, by November 15, 2014) of the number of employees and family members covered during that year. HHS will then notify the carrier or plan by December 15 of that year regarding the reinsurance contributions to be paid for the year. As stated above, payment will be made in two installments and each installment payment must be made by the carrier or plan within 30 days after the invoice date. States have the option of requiring their own, additional reinsurance contribution, which will be collected along with the federal amount. However, that state-collected fee will apply only to fully-insured plans and not selfinsured plans. A sponsor of a self-insured group health plan that pays the reinsurance fee may treat the amounts paid as ordinary and necessary business expenses, subject to any applicable disallowances or limitations. This treatment applies whether the contributions are made directly or through a third-party administrator. Counting enrollees Proposed regulations prescribe five different methods for determining the annual enrollment count (with some similarities to methods applicable to the PCOR Fee described above): Actual count method. The sum of the lives covered for each day of the first nine months of the calendar year, divided by the total number of days in the first nine months. Snapshot method. Add the total number of lives covered on one or more days during the same corresponding month in each of the first three quarters of the calendar year, and divide that total by the number of dates on which a count was made. The same months must be used in each quarter (for example, January, April, and July), and the date used for the second and third quarter must fall within the same week of the quarter as the corresponding date used for the first quarter. Snapshot factor method (self-insured plans only). This method is the same as the snapshot count method, except that the number of lives covered on a date is calculated by adding the number of participants with self-only coverage on that date to the product of 2.35 multiplied by the number of participants with coverage other than self-only on that date. Form 5500 method. Based on the number of reportable participants for the Form 5500 that is filed for the applicable self-insured health plan for that plan year. For most plans, which provide coverage for multiple tiers (self-only, employee plus spouse, employee plus family, etc.), the method allows a plan sponsor to simply add the number of participants reported on a 5500 for the beginning of the plan year to the number reported for the end of the plan year to determine the average number of covered lives for the plan year. For a plan that happens to provide only self-only coverage, the plan sponsor may treat the average number of covered lives under the plan for a plan year as the sum of the total participants at the beginning and the end of the plan year, in each case as reported on the Form 5500, divided by two. Member months method or state form method (fully-insured plans only). Multiply the average number of insurance policies in effect for the first nine months of the calendar year by the ratio of covered lives per policy in effect (calculated using the prior National Association of Insurance Carriers Supplemental Healthcare Exhibit, or a form filed with the insurance carrier s state of domicile for the most recent time period). Health Insurer Fee The overall purpose of the Health Insurer Fee is to assist in funding new obligations of the federal government under the ACA, including subsidies for certain individuals buying coverage through a health insurance exchange. The Health Insurer Fee applies covered entities, which include any entity which provides health insurance for any United States health risk and will apply to medical, dental, and vision insurance. It will not apply to the following types of insurance coverage: Accident-only Long-term care Disability Disease-specific Hospital indemnity Other fixed indemnity
5 Legislative Alert Page 5 Any self-insured plan, including a health reimbursement arrangement (HRA) or health flexible spending arrangement (FSA) Government entities and certain nonprofit entities are excluded as covered entities, though it appears this applies to their roles as providers of health insurance for a U.S. health risk, not in their roles as policyholders of commercial health insurance products. Regulators issued proposed regulations in March These regulations reiterated the applicable amount, which is the aggregate annual fee for all covered entities and is $8 billion for calendar year 2014, $11.3 billion for calendar years 2015 and 2016, $13.9 billion for calendar year 2017, and $14.3 billion for calendar year The fee continues indefinitely and the rate of premium growth rate is used to index the applicable amount for years beyond That applicable amount is allocated each year among the includable covered entities based on relative market share of U.S. health insurance business. Specifically, each covered entity will be responsible for a portion of the total applicable amount based pro rata on the covered entity s net premiums written during the preceding calendar year for health insurance for any United States health risk, relative to the aggregate net written premiums of all covered entities during the same year. The allocation will not take into account covered entities with net written premiums from the previous calendar year of $25 million or less. For covered entities with net premiums of more than $25 million but not more than $50 million, only 50% of premiums will be subject to the allocation. This means that large insurance carriers (and their policyholders) will be responsible for a significant portion of the Health Insurer Fee. The fee is paid in each calendar year, with the first fee payments due by September 30, One analysis estimates that the insurer fees will increase premiums in fully insured coverage markets by an average of 1.9% to 2.3% in 2014 and by 2023 the fees will ultimately increase premiums by an average of 2.8% to 3.7%. ( Estimated Premium Impacts of Annual Fees Assessed on Health Insurance Plans, Chris Carlson, FSA, MAAA; Oliver Wyman, October 31, 2011). In short, sponsors of insured plans should be prepared for renewals reflecting up to a 2.5% increase in premiums above the trend in premiums, with the possibility of an additional 1% to 2% for years following See next page for a summary of ACA fees. This material is provided for informational purposes only based on our understanding of applicable guidance in effect at the time of publication, and should not be construed as being legal advice or as establishing a privileged attorney-client relationship. Customers and other interested parties must consult and rely solely upon their own independent professional advisors regarding their particular situation and the concepts presented here. Although care has been taken in preparing and presenting this material accurately, Wells Fargo Insurance Services disclaims any express or implied warranty as to the accuracy of any material contained herein and any liability with respect to it, and any responsibility to update this material for subsequent developments. To comply with IRS regulations, we are required to notify you that any advice contained in this material that concerns federal tax issues was not intended or written to be used, and cannot be used to avoid tax-related penalties under the Internal Revenue Code, or to promote, market, or recommend to another party any matters addressed herein. Products and services are offered through Wells Fargo Insurance Services USA, Inc., and Wells Fargo Insurance Services of West Virginia, Inc., nonbank insurance agency affiliates of Wells Fargo & Company. Products and services are underwritten by unaffiliated insurance companies except crop and flood insurance, which may be underwritten by an affiliate, Rural Community Insurance Company. Some services require additional fees and may be offered directly through third-party providers. Banking and insurance decisions are made independently and do not influence each other Wells Fargo Insurance Services USA, Inc. All rights reserved. For public use.
6 Exhibit A: Summary of ACA Fees Fee Effective dates Party responsible for fee Annual fee amount Fee due date PCOR Fee Funds research on the effectiveness, risks, and benefits of medical treatment through the Patient-Centered Outcomes Research Institute. 7 years only Plan and policy years that end between September 30, 2012,and September 30, 2019 Fully insured carriers Self-insured plan sponsors file Form 720 Applies to medical and integrated dental and vision plans, excluding excepted benefits $1 per participant per year for first applicable plan year $2 per participant per year in plan year two $2 per participant, increased by the medical inflation rate, for next 5 plan years Tax deductible for employers Fees are to be reported on IRS Form 720 (Quarterly Federal Excise Tax Return) and paid once a year. Payments are due no later than July 31 of the year following the last day of the policy or plan year. Transitional Reinsurance Fee This fee will support the transitional reinsurance program to provide subsidies to carriers offering coverage on the Exchanges. This fee aims to stabilize premiums for coverage in the individual market and lower the effects of adverse selection. 3 Years Only Plan and policy years beginning January 1, 2014 Fully insured carriers Self-insured plan sponsors and administrators Applies to medical and integrated dental and vision plans, excluding excepted benefits Total amounts to be collected are $12 billion in 2014, $8 billion in 2015, and $5 billion in 2016, totaling $25 billion. Some states may also assess their own fees in addition to the federal tax, but applicable only to insured plans. $5.25 per member per month, or $63 per member per year, reducing in 2015 ($44 per member per year) and 2016 ($27 per member per year) Tax deductible for employers Enrollment data must be provided to HHS by November 15. HHS will notify the contributing entity by December of benefit year 2014, 2015, or 2016, as applicable, of the amount of the contribution for the year. Contributions will be paid in two installments the first installment will be invoiced by December 15 of the benefit year and the second installment in the fourth quarter of the following calendar year, with payment for each installment due within 30 days after the invoice date. Health Insurer Fee An annual, permanent fee on health insurance providers to fund premium tax subsidies for individuals and families with household incomes between 100% and 400% of the federal poverty level who purchase health insurance through the Health Benefit Exchange. Ongoing Tax years beginning January 1, 2014 and later Unclear when first payable by carriers, though carriers are building the fee into 2013 renewals that carry over into 2014 Fully insured only carriers Generally includes medical, dental, and vision coverage Expected to be approximately 2% to 2.5% of premium, increasing to 3% to 4% in later years. Based on the insurer s market share of net premiums written based on the previous year (that is, 2014 fee will be based on 2013 premiums). Total fee amount to be collected from all insurers starts at $8 billion in 2014 and increases to $14.3 billion in After 2018 the fee increases annually based on premium growth. Tax deductible by the employer Each covered entity is required to report its net premiums written for health insurance by April 15 of the fee year on Form 8963 (Report of Health Insurance Provider Information). The IRS will notify covered entities of their preliminary fee calculation by June 15 of the applicable year. Covered entities will then have until July 15 to submit a corrected Form 8963 (if necessary). After the error correction process is completed, the IRS will provide each covered entity with a final fee calculation by August 31 of the fee year. Fee payments are due by September 30 of the fee year.